Julia Manning

November 09, 2010

As I write this, David Cameron is flying with his all-male ministerial team to meet President Hu Jintao and Premier Wen Jiabao of China. Questions were asked in the press yesterday about whether he will raise the issue of the human rights of Nobel peace prize winner, Liu Xiaobo. But in a country where experts estimate that about 100 million girls have been aborted, murdered, disappeared or trafficked I sincerely hope he will be raising this far greater human rights travesty.

Featured on the cover of the Economist back in March with accompanying superb articles, it is twenty years since another Nobel prize winner, Amartya Sen, published an essay in the New York Review of Books highlighting what he described as "what is clearly one of the more momentous, and neglected, problems facing the world today." And yet, nothing has changed. Impotent posters adorn walls in China, telling people that girls are equal to boys. Their mothers are obviously not convinced. And this is the other side of the tragedy - girls that have survived to become mothers still have such little self-esteem, such a sense of inferiority, such a fear of poverty or their daughter's abuse (maybe) that they will get rid of their baby girl in order to have a son. And that can be through abortion, infanticide, sold into the sex trade or dumped in an orphanage. 95% of children in Chinese orphanages are healthy baby girls; but such is the culture of neglect that deaths are frequent, in one case reaching 76% (as detailed in Death by Default).

It wasn't always this way. Chairman Mao gave women the legal right to vote, education, employment, marriage and inheritance rights. Their status was transformed, until in 1978 Deng Xiaoping brought in economic reforms that began to increase discrimination against women once again. It was a year later that the one child policy became law. By 2020 the Chinese Academy of Social Sciences estimates that there will be 40 million more men aged 19 and under than women. That will be equivalent to the total number of young men in the same age bracket in the USA. Demographers can only guess at the societal impact. Already this increasing scarcity of women has spawned another nightmare. According to the US State department, domestic trafficking of women is now the most significant problem in China with up to 20,000 women trafficked each year, sold as 'brides' or into sex slavery.

So I hope our Prime Minister ask: when laws designed to protect women will be enforced? When will doctors will be prosecuted for an unequal male-female abortion ratio? Maybe Michael Gove can ask when will school fees will be abolished that have left 100 million girls illiterate in what is now the worlds second biggest economy? When changes to social security will ensure the parents of girls are not penalised in old age? Amartya Sen was asking such questions 20 years ago. I can't help feeling that it's a shame that a female cabinet minister isn't with him who could have embodied our political commitment, albeit imperfectly executed, to gender equality and status.

September 17, 2010

I grew up with Zambia and Zimbabwe, but I only stepped on
their soil for the first time in August. The flimsy, blue airmail letters which
when I was a child brought monthly news of my cousins, of Kaunda then Mugabe,
of sadza, puff adders, Lusaka, Livingstone and Harare were read out loud and
left me with vivid memories. My aunt and uncle left the UK in 1970, and my
cousin (one of five) with whom we are staying has lived half her life in Zambia,
and the latter half in Zim. Now an awards-winning expert in wild dog and
cheetah, she works with governments across southern Africa, promoting the
co-existence of wild-life, farm animals and humans.Living and traveling with her family for
three weeks meant we had the chance to glimpse Zim life which she is at pains
to say, gives her no authority to speak for others. Knowing a little about the
shattered lives and pain of fellow citizens, sharing whatever they could
whenever they could, feeling the impact of famine and fear but being able to
evade the consequences leaves her humbled and not daring to assume anything on
behalf of those for whom devastation was a reality they couldn’t escape. But
she and her husband are also determined that their country should not be a
hostage to the past, details of which much is still unknown because fear
remains a silencer while Mugabe lives.

And there is no doubt that they are waiting for Mugabe to
die, as the only way he will leave office now is in a coffin. Hopes of
overthrow or resignation never materialised, partly because of the refusal of
Zim’s neighbours to support regime change and also the cultural commandment
that you never challenge an elder. What is less clear is who will replace him.
There are two high profile bitter rivals: vice-president Joyce Majuru who has Army
support; and Defence Minister Emmerson Mnangagwa who has the backing of the Intelligence
and a reputation for evil. But of course they shouldn’t even be in office. Refusing
to budge is not an unknown phenomenon in these parts and when the polls showed
that Mugabe had lost the election in 2008, he rejected the people’s decision
and insisted on staying. After pressure from Zim’s neighbours he offered the
sop of sharing some power with the rightful victor, Morgan Tsvangirai’s MDC-T
party. Tsvangirai, who for many years has fought peacefully for democracy, eventually
accepted that this compromise was the only nonviolent way out of the impasse. This was grace personified as Tsvangirai and
other MDC officials started to work alongside ministers who had been responsible
for their beatings and persecution and the deaths of supporters.

Elections are scheduled again for next year, following a referendum
on a new constitution which should be put to the country by February. Whilst constitutional
consultations are being held around the country, the process is being subjected
to the usual Zanu-PF treatment of intimidating the rural population into
accepting Zanu’s ‘Kariba’ draft which would, amongst other things, allow Mugabe
two more terms in office. He’s 86 and showing signs of intellectual
deterioration so this is optimistic.

What became clear to us as we listened to people’s stories was
that whilst Mugabe is responsible for the deaths and intimidation of hundreds
of thousands of people, he is no ethnic cleanser. He is not interested in your
tribe, only your support. His obsession with power knows no boundaries, to the
extent that he conscripted the nation’s children into a control force from 2000
onwards. This youth militia were teenagers told they couldn’t get a job in the
public sector without joining the National Youth Service. Subjected to
beatings, abuse and brainwashing they were then sent to dispense fear and
violence on MDC-T supporters before the country’s elections. One of the key
democratic indicators will be the response of these ‘Green Bombers’ at the next
election, many who now hate Mugabe but who also fear his reach and know his
mercilessness.

Democratisation will also be influenced by the response of
Zim’s neighbours, especially Zuma’s South African government at the time of
Mugabe’s death. Will they finally intervene and insist on the verdict of the
ballot box? Their experience too of ‘truth and reconciliation’ hearings could
be invaluable in a country that would need to go through the healing process of
understanding the past, whilst not being defined by it. And it would be wise for
Zuma and his fellow Southern African Development Community (SADC) leaders to
anticipate the ramifications of Zanu-PF’s illegal requisition of the Marange
diamond mine. Discovered just four years ago, it is reported to be the biggest
in the world, and locals were simply gunned down as Zanu and the Army moved in
to take control. Although some sales of the industrial diamonds were recently ‘approved’
by the Kimberly Process, these blood-diamonds have already given Mugabe the undeserved
gift of a totally new revenue stream and another reason for his Army to oppress
their fellow men.

Yet in this country where the soil is rich, where there are
enough natural resources to produce power and create wealth, which is breathtakingly
beautiful and in which their citizens take such pride, there is still hope. When
we sat with people and talked they would smile and said ‘you are here, we are
not forgotten, there is hope’. The message I took away from time with staff at
Mpilo Hospital (as described in my last letter) is however that this hope is
fragile. Tsvangirai hasn’t delivered the transformation they yearned for and despite
the tangible improvements, doubts are now expressed about further progress. Their
disappointment is understandable. They have been patient for so long, risking
so much to vote MDC-T for four elections now, never retaliating with the
currency of violence that is spent so freely by Zanu-PF conscripts. Politically
it seems to me as an outsider that right now Tsvangirai is doing all he can,
hemmed in by corruption, injustice and lacking the international support that
hope-to-God will rise when Mugabe dies. And
practically, while excess has sapped the inspiration of hardship in the West, scarcity
here stimulates stewardship and initiative that is humbling. Zimbabwe is still
a country to be respected, despite its president.

September 04, 2010

Mpilo Hospital in Bulawayo used to be one of the best in Africa. The retired Clinical Director who met me remembers it in its heyday and worries that the number who know what it was, what it should be, are dwindling fast. There are still hundreds of patients turning up every day but while diagnosis may be possible, treatment often isn’t. The skeleton staff who work here have virtually no resources and have to work around the power cuts that are a daily occurrence across the city. Last year, their hopes for improvement were raised by the power-sharing agreement between Mugabe’s Zanu-PF and Tsvangirai’s MDC-T and the appointment of Tendai Biti as MDC-T Finance Minister. But where Biti has brought desperately needed financial stability through adopting the US dollar as currency, the huge debts and fractured infrastructure he inherited (that for instance means everything is bought with cash, there are no electronic debit or credit card facilities anywhere) has hampered recovery.

Things are definitely better that they were last year. Supplies that totally dried up pre-February 2009 are now occasionally getting through to the Hospital. The day I was there, pethidine had arrived, the first painkiller for mothers in labour or post caesarean section that they had had for months. But where the facilities were rich in their space and their few dedicated staff, poverty paraded itself in an absence of bed sheets and equipment. There was no monitoring (not even a working blood pressure gauge), no food, no MRI or working CT scanner. The technical manager said he was desperate, if only he had the parts to fix the autoclave sterilisers they could then reduce infections. In the maternity unit, two midwives were seeing to 16 women in labour and simultaneously training eight students. The going rate is $43 for a hospital delivery, but no one is turned away in a country of 90% unemployment. Another two midwives oversaw the 168 post-natal beds with unqualified assistants. A 27 week old baby wriggled in the solitary incubator box but without the vital piped oxygen mask and over-hydrated on an adult drip. Other tiny, malnourished forms were held by their mothers, with the only measure of progress the ingestion of milk and a nod from the head nurse.

The one theatre has no anaesthetist but relies on a (now) specialised nurse who has learned on the job; and an ancient, slow steriliser means that in an emergency equipment in just washed and re-used. We can treat an infection, they say, we can’t treat a dead mother or baby. Amazingly they have delivered 4,850 babies in the last six months and only 151 babies (3%) and 19 mothers have died. 25% are HIV positive (the only HIV screening in the country is done on expectant mothers), which is down from the 50% rates of the 90’s. But the life expectancy remains stubbornly low at about 40 years, and it was only after being in Zim for a couple of weeks that I realised I could count the elderly people I had seen on one hand.

Professionals left the countries in their thousands after the land-grabs of 2000 began. In the rural areas, the clinics that Mugabe had specifically developed to ensure no woman was more than a day’s walk away, could no longer retain their staff who were fearful for their lives. But as the country descended into violence and chaos, there was no money to pay them anyway. By coming to work overseas, including in our NHS, professionals at least had a job and could send money home to parents and children left behind. The distribution of medicines waned with supplies drying up and unstaffed clinics, which is partly why last years cholera epidemic was so devastating and experts are fearing a rise in deaths from Aids as HIV medicines can’t be obtained. Cholera kills more quickly and there simply weren’t the facilities to treat the tens of thousands who became victims of the breakdown of the sanitation and water systems particularly in the east of Zim. Likewise the question of the impact of virtually no public health provision (beyond a successful NGO-run child vaccination programme) on the 70% of the population who are rural, on infections, on child mortality, can only have a heartbreaking answer.

The extra dollars promised for the hospital staff to boost their incomes from $200 a month to $3-400 is only occasionally getting through. But that’s nowhere near enough to lure staff back from the Zim diaspora. There are three general surgeons left in the Bulawayo region who are the only hope for anyone requiring any operation in western Zim. Last year, local people came to see the hospital, and they were so moved by the difficulties they saw that they raised funds for the broken down mortuary and laundry. Both are working again and the ex-Director is convinced that getting local people involved in their hospital is the way ahead, along with a new wave of training up medical staff. The recent relaxation of regulations means that Mpilo can raise its own funds and start to form contracts direct, instead of being stifled under the dead-hand of Harare bureaucracy or waiting for political nirvana. Ideas are bubbling in our minds as to how we can magnify these glimmers of hope as we end our visit in the Chief Execs office. I have left Mpilo, grins the former Director across the table, but Mpilo hasn’t left me. For myself, I can only guess and feel profoundly humbled at the depths of dedication and sacrifice displayed by the staff who are still here, trying to serve, wanting to heal. I am blown away by the tenacious spirit of those I have met. Yet I am also acutely aware that I am only meeting the survivors.

August 31, 2010

At 2pm today inSennen Parish Church, a mile from Land's End, flowers
will be laid on the grave of a remarkable woman, and there will be a fly-past,
hinting at what the commemoration is for. We are very familiar with 'firsts' in
history; the first circumnavigation of the globe; the first landing on the
moon; the first to invent a light-bulb or discover the cure for smallpox.
However what comes afterwards is often as impressive, as the achievement is
copied or refined or bettered, not least when done so against the odds.

Seven years after the Wright
Brother's invented, built and flew first plane, the first woman to gain her
'wings' was Elise Daroche, a frenchwoman in March 1910. However for the previous
six months, Lilian Bland, Kent-born but of Irish descent, had been toiling in a
workshop at her aunt's house north of Belfast. She had been inspired by her
experiences watching birds as a photographer and from a post-card of Louis
Bleriot's plane that had crossed the English channel in July 1909, she had
convinced herself that she too could fly. But she had no interest in simply
flying; she wanted to build her own plane.

Visiting the first ever
Blackpool Aviation Meet in October 1909, she took detailed notes of all the
crafts on display, many of which couldn't actually take off, and from these
made a 6ft span model biplane glider back in her workshop, which flew when
towed. From gelatin and formalin coated calico to cover the wire and wood wing
structure, to a custom-made A.V.Roe engine that she ordered and collected in person from Manchester, the
full-size bi-plane then came together and was christened the Mayfly. It may
fly, she reasoned, it may not. So excited was she at the arrival of the engine,
that the need for a fuel tank had been overlooked, and in true Apollo 13 style,
a whiskey bottle and ear trumpet belonging to her deaf aunt became temporarily
seconded to do the job.

After months of testing and
refinement, on August 31st 1910, the Mayfly took off with Lilian at the
controls. Her achievement was recorded in the Belfast Telegraph a few days
later. Although she was only five days ahead of the first American woman to
fly, she was exceptional as a pioneer in aviation having constructed her own
aeroplane and shared much of her learning, not least through two years worth of
letters to ‘Flight Journal’. Yet the only reason I know about her is that she
was my great, great aunt who died when I was three and one of those laying flowers on her grave will be my dad. Her story has made me
wonder at the untold stories of women, who have been inspired by challenges and
made significant advances in history. Is it because they were refining the ‘firsts’
of men that they are neglected in our history books, and/or because like Lilian,
they were considered unladylike and rebellious? Are they really few and far
between, or are there many unknown knowns out there, waiting for their stories
to be told and the chance to rebalance the gender bias of our history books?

July 01, 2010

A welfare 'revolution' has begun to whirl through Whitehall with Osborne, Grayling and IDS all hurrying to
slash the millions that are spent on Incapacity Benefit through re-appraisals of recipients ability to work and moving them onto 'active' benefits that require them to look for work. That is the right thing to do as there are scroungers who have been fleecing the treasury for years. But there are also those who have been utterly failed by our health-care system. They have not received the support they needed from their doctor or employer, or been denied the apposite medication. Left without the early intervention that could have kept them in or got them back to work quickly, a short term health investment in support has turned into a long term welfare cost.

2020health launched their latest report this morning Health, disease and unemployment: The Bermuda Triangle of Society with a salient reminder that sick people require quick and appropriate health-care in order to keep them in or get them back to work. It's a two-way street: you need to be healthy to be in work - but work usually has a positive impact on people's health as well. The link between unemployment and poorer health is well established. People with chronic conditions who have not had the necessary support then get caught in a downward spiral of unemployment, deteriorating confidence and poorer health. At our round table round-table debate we discussed the vitally important mindset change that needs to take place amongst the NHS workforce: getting people back to work as quickly as possible should be a measurable clinical outcome of successful treatment.

Dame Carol Black has been the pioneer in this field and continues to lead the joint working between the DWP and DH on Health,Work and Wellbeing. The 'Fit note' that replaced the 'sick note' was her idea and it is a really positive way of encouraging GPs to think about what work people can do, rather than just signing them off work. However there remains a gulf between most clinicians at the frontline and any employment services. The high level joint working approach achieved by Dame Carol needs to reach those actually working closely with those who become ill, many of whom are desperate to get back into work.

There is no silver bullet, but the transformation of occupational health, a progressive approach from company's HR departments, inclusion of occupational training in the post-graduate medical curriculum and ensuring existing Health and Safety rules on stress reduction in the workplace are enforced are all steps in the right direction. Public health needs to reach the workplace if we are going to have the workforce we need and spending on welfare-to-work must be partly funded by the health budget if health professionals are going to take a 'healthy workforce' seriously.

June 01, 2010

I wonder what you thought of the recent watershed in advertising of abortion
on TV? No matter what your stance is on abortion, something significant happened last
week.In allowing the advert to screen,
we took another step in the direction of the commoditisation of humanity,
without considering as a society what message we are sending when terminating a
life becomes a TV sound-bite.

The TV advert was of course for a private service, although the provider,
Marie Stopes, also earns about £30m from their contract with the NHS.I believe there are fundamental issues that
we should step back and consider deeply before taking any further steps, but
there is also a basic issue of conflict of interest and misinformation. How can
a business that relies on conducting abortions for its income be a credible
source of balanced ‘choices in reproductive healthcare’ to the NHS, offering
all the alternatives? It can’t and it doesn’t.

But of greater significance are
the medium of the advert, the move to abortion-as-contraception and
commoditisation. Is the medium of TV advertising for one of the
deepest, most profound decisions any woman can make really appropriate? In a 30
second sound bite all the complexity, dilemma and significance is swept aside. A
choice, that for some of my friends has shaped and shadowed their lives ever
since, is reduced to the level of washing powder options. This relates directly to the medium. Despite
worthy ‘edutainment’ exceptions, TV is still mostly about entertainment. We
watch it to relax, to be amused, diverted. I may not agree with all Neil Postman
wrote about television in ‘Amusing ourselves to death’ but he has a salient
point – which is that on TV, ‘entertainment is the format through which all
experiences are mediated’.

When abortion was legalised, the expectation was that it would be an exception.
If no other alternative of support or adoption was feasible, or the mother’s mental
health or physical life was as risk or the baby was severely disabled then at
last there was an alternative to the back-street butchers. But that naivety was
short lived as year on year, terminations have increased to the point we are at
today, roughly 190,000 annually with 99% for social ‘inconvenience’ reasons (and isn't an advert designed increase numbers?) Multiple
terminations, once considered unthinkable, are increasingly common and we can
no longer ignore the fact that has become a form of contraception. Former
denials of this as a possibility from all sides indicate our discomfort with
the notion that women could be so cavalier. But some are, and are we content to
continue to proclaim their unending right to £400 terminations when a contraceptive
pill costs 10p and the NHS abortion bill is pushing £80 million?

And although there is a purely economic argument for confronting the
statistics, there is the more fundamental one of humanity. In our throw-away
society haven't we lost something crucial when new life is viewed as just so
disposable? Another commodity to be kept or thrown away at will? Just another
consumer choice? Because this mindset logically cannot be retained only for the
unborn. In moving abortion from a solution to a personal crisis to a lifestyle entitlement
we belittle all human life; sensitivity to frailty is weakened and we are all
diminished.

TV ads have been used by Oxfam and other charities to raise money to highlight
serious issues such as famine, neglect and disaster. The subject is usually a
clear cut tragedy with no moral ambiguity, and though we may become impervious,
there is a simple response. People need food, abuse must stop, homes rebuilt. Abortion
is different. It is a profoundly divisive and morally complex issue with
permanent, personal consequences. A 30 second advert can never provide a
balanced view.

May 21, 2010

Craig Venter is the 'Boris' of Biology and there is no denying that his passion for progress in genetics and slightly worrying drive to create Artificial Life is genuine.

What they did: In short his team made a synthetic copy of a bacterial genome (of 500 genes - we have about 25,000) and inserted it into another live host bacterial cell whose own DNA had been removed. This second cell was then only being controlled by the synthetic genome, as it's the DNA in the genome that directs the cell's activities. So this combination of synthetic genome plus the (already live) host was something totally novel, and the proof that it 'worked' is that this new bacteria went on to divide in the normal way that bacterial cells do.

Why it's not artificial life: While this is a significant achievement which took 15 years and £30m to create, I would argue however against the Economist's claim that 'mere mortals have now made artificial life' for the two main reasons. Firstly it's a copy of an existing, naturally occurring genome; and secondly it wouldn't have got anywhere without the live host cell, and all the essential stuff (polymerase enzymes, ribosomes, mRNA, mitochondria, cytoplasm) that the host cell contained. We haven't created new life-giving chemicals or designed a previously unknown live creature. And although the speed of DNA synthesis and experimentation is increasing, the staggering complexities of gene expression, incompatibility of genetic 'parts' and unpredictability of the cellular 'circuits' still constitute massive hurdles to progress.

Policy Implications: However the policy implications are still huge. For a start, if 'progress' is defined as steady improvement, what are we trying to improve, and why? And what are the risks of pursuing 'progress'? With such little public engagement in science, people will worry about what this means to them, to life, to safety. Life scientists will worry about 'GM' type rejection and security specialist's concern will revolve around the ignorancee of life scientists who are unaware of international treaties that exist to reduce bio-error. We may not be able to create artificial life, but someone could create artificial smallpox.....

The call for a moratorium from Human Genetics Alert on this science is no bad thing. It will raise the profile, allow us to analyse the benefits and assess the risk - ultimately increasing the public's confidence in decisions made. We shouldn't continue regardless just because we can.

May 06, 2010

My son announced that they had had their school mock election last night, and that he had voted UKIP. He's getting really good at being a really bad wind-up merchant. And he didn't come clean straight away; he then declared he'd voted Labour before finally saying 'How could I betray you mummy? Of course I voted Conservative'! Salient point - a vote for any other party is a betrayal. He was thinking on a personal level, I am thinking on a national one. This country is leaking debt in a way that rivals the crude flows from the damaged Gulf oil rig - but more about that in a moment.

I was thinking last night that it was a bit like Christmas eve: no idea what 'present' we are going to get today; planning on being with family and friends; staying up too late; a no-news day (are exit polls really news?) and everyone's mind is on the same thing....

Yet I don't think it hasn't turned out like we thought it would. Fascinating though the leadership debates were, they have left many with a firm impression of the leader they like but varying levels of confusion over how they would lead. How do we move on, taking the benefits of engagement from the leaders debate but reducing the costs of confusion?

Subjects we thought would be key turned out not to be. Where has the NHS been apart from the cancer confusion (a voter told me yesterday he wouldn't vote Tory as they were cutting cancer medicines...)? Why haven't we heard more on Afghanistan? Immigration, a taboo at the last election, has been a hot topic. And what happened to the 'mumsnet' election? Women have not been seen, let alone heard. Ok, that's a mercy when we're considering Harriet Harperson, and Stephanie Flanders is a superb media exception, but I wonder if Gordon's 'that woman' jibe reflected the all too frequent macho irritation with having to consider a female perspective?...

We know of course that it always comes down to 'it's the economy, stupid' but truly, hasn't that turned out to be this year's taboo? i.e. How to tackle the deficit? In my humble opinion, the only reason we aren't still in recession is the billions Labour has spewed into the public sector that have created a false-positive in economic growth. They won't admit it; the Tories can only guess at the severity of the spillage and for an ex oil-man, Vince has remained typically opaque.

I am longing, hoping and praying for a Conservative victory tonight so that George Osborne can put in place his equivalent of the 100-ton concrete-and-steel contraption for oil siphoning and apply it to the debt that has polluted our future. Like the oil, so much damage is done and it will contaminate the nation for a long time to come. So just as this election has not turned out the way we thought it would, here's hoping the the real poll turns out better than we have been led to believe. Off I go to GOTV!

April 13, 2010

People power is set to be the central theme of the Conservative Manifesto
being launched later this morning. And this is the clear contrast between the Tory
Party and the Labour Party: the Tories have moved from giving us a hand-up
to enabling us to step-up; Labour have remained as the hand-out Party. And
the stepping-up opportunities in health will come in different forms, from facilitating
John Lewis style partnerships in healthcare organisations to demanding the publication
of outcome data instead of process targets to inform patients, to real budget
holding for GPs and patient-held records.

2020health itself was instigated as a response to me and my NHS colleagues’ despair
at being utterly disenfranchised when it came to using our expertise to improve
healthcare. Capturing the talent of the workforce and opening up opportunities
for patient-professional-public collaboration is the re-enfranchisement that we
have been waiting for. Yet I can hear the howls of opposition already, from the
blinkered jobs-worth and the mediocre manager, previously sheltered and sure of
a job and pension for life, turning wild-eyed to their union reps at the
prospect of being held accountable by the people they purport to serve and having to account for their role. About
time, but public sector employment terms and pensions are also in need of
serious overhaul and as yet we don’t know if this will be mentioned.

Yet as I wrote in our own What Women Want Health Manifesto in March, there
are still ‘demand’ giants to be slain in the NHS – neglect, risk, drift, commoditisation
and conflict – and unless and until we tackle these, the NHS remains on a course
of unsustainable expansion. Interestingly as the 2020health GE2010 Health Policy Tracker shows, at this
stage there seems to be an emerging consensus between Tory and Lib Dem health
policy. This may change tomorrow with the latter’s manifesto, so watch this
space.

March 23, 2010

Ok, the above title is paraphrasing. But the attitude demonstrated by Jack Straw at 8.10am on the Today programme will only fan the flames of disillusionment already felt by the public towards their political representatives. The Taxi-gate 4 did "nothing wrong" and they were "stupid" because they were "suckered into a sting", Not because they abused their positions, Jack? Not because they have dealt another blow, post expense-gate, to the standing of the British Parliamentarian? Not because they have broken the spirit of the law, if not the letter? Making a case because you feel it's right (call it lobbying if you will) should be considered (informed) bias - making a case for cash when you hold public office should be considered corruption.

And no investigation is to follow. No public light will be shone into the opaque heart of government. No one will lose their job. No trust will be restored.

March 22, 2010

2020health’s report on “Fixing NHS IT” is published today
and featured in the Financial Times and on smarthealthcare.com. In it we detail how incoming government could save at least £1 billion
by realigning the troubled NHS computer programme and boosting its performance. We have compiled an unprecedented dossier gleaned from extensive
interviews with key participants of what has worked, what should be stopped and
what next.

Our detailed rescue plan for
the £12 billion National Programme for Information Technology (NPfIT), which was launched
with a great fanfare by Tony Blair in 2002 but now mired in cost over-runs and
a four-year delay, is, we argue, essential for the future of UK healthcare.

The NPfIT was supposed to link 30,000 GPs to nearly 300
hospitals across England,
providing NHS staff with instant access to the medical notes of patients at
every stage of diagnosis, treatment and discharge. It consisted of national
infrastructure, an NHS Spine, integrated with local care records services.

MPs on the Commons Public Accounts Committee warned last
year that key parts of the programme –
the biggest civilian IT project in the world –
were on the brink of failure and that the revised completion date of 2014-15
(four years behind schedule) looked over-optimistic.

Our study, conducted by 2020health.org and written by NHS
IT expert John Cruickshank, warns that a hiatus for NHS IT after the
election expected in May would be hugely detrimental to patient care. We based our findings on confidential interviews with NHS
officials and the private contractors tasked with upgrading NHS IT.

The report’s starting point is to state that getting NHS IT
right is critical for a new government. IT-enabled new ways of working are
essential to enable the NHS to meet ever-growing health demands whilst also
achieving its productivity targets and improved outcomes.The study then does a
rigorous analysis of NPfIT, and dispassionately considers its successes and
failures. It argues that the perception that the problem can be fixed simply by
axing the Programme and localising everything will only makes things worse.

March 16, 2010

The BBC have covered this morning a report by the Self-Care Campaign that is singing from the same hymn sheet as 2020health's reports on Responsibility in Healthcare and our What Women Want manifesto: unless we encourage, nudge, educate, incentivise, whatever towards self-care, the 'dependency culture' will continue to drain the NHS of vital resources that are desperately needed for those with serious illness.

Using stats published in August last year, today's report identifies that one fifth of GP appointments are a waste of their time - coughs, colds, backache, dermatitis, constipation. (Even now I can hear the relevant campaign groups reaching for their keypads to write and tell me of all the deadly diseases of which these 'innocuous' symptoms can be the first sign - no need please - we're simply advocating common sense and discretion). Privately I have had GPs tell me it's up to 40% that are unnecessary. And there are no tears being shed over the potential loss of these patients as they are currently having to be fitted in around the greater number of patients being treated 'in the community' i.e.by the same GPs.

Some say this 'dependency' dates back to the inception of the NHS; I'm not sure about that - but what I am sure of is that over the last 12 years, the emphasis on easier access to health professionals, extension of 'free' prescriptions and knowledge that we are treated no matter what has been interpreted by too many as an entitlement with no obligation. It's unaffordable.

All Parties should be embracing self-care as a common sense part-solution to a long term sustainable healthcare system. It's simple: more self-care = fewer cutbacks. It should be part of a four way deal: industry should be providing more health services; individuals should be using health services more wisely; professionals should be enabling self-care and the government should be ensuring the highest standards of care, practice and information are disseminated and implemented.

March 08, 2010

2020health.org has today, on International Women's Day, published our Manifesto for Health. Called 'What Women Want' it features 17 female authors writing about their hopes for health from the next Government. They are all writing in personal capacities, but one GP who happens to be the President of the Royal College of GPs is featured in the Daily Mail today. Prue Leith writes about the importance of nutrition, Su-Anna Boddy writes as the fist ever mother on the council of the Royal College of Surgeons, Baroness Jill Pitkeathley writes about the importance of elderly care and physiotherapist of the year Nicola Hunter highlights what community based physio could deliver - to name but a few.

Publicly valuing the contribution of women is crucial to freedom and democracy. If freedom is to be sustainable it is not about having choice per se, but about making the right choices. And to make the right choices we need the full picture - which is partly enabled by having both male and female perspectives. Decisions then have an enhanced legitimacy and could well be more effective.

Some feminists have got feminism a bad name which is a real shame because who could disagree with the egalitarian principles of social, political and economic equality for women? Yet when it comes to policy, recent all-male or male dominated publications and events, inexcusable in a democracy, have demonstrated that women are still not being given enough opportunities to be heard. We hope this publication will go someway to redressing the balance.

February 24, 2010

The travesty at the centre of the Mid Staffordshire NHS Trust disgrace that led to hundreds of avoidable deaths and exacerbated sickness and disease amongst others is the culture of fear that reigns in many NHS organisations. It is appalling that staff at all levels feel they have to chose between integrity and income. We have heard stories where nurses are reminded every week not to reveal poor practice; where doctors are bribed with bonuses and where management edit the minutes of meetings to ensure the public record doesn't look bad.

The current whistle-blowing provisions are clearly not working and must be urgently revisited. Staffordshire needs a public inquiry for justice to be done and for families of the deceased and maimed to know that their pain has been heard and that improvements will be embedded across the NHS.

In a profoundly challenging fiscal environment it will be essential to ensure safety for patients through safeguards for staff whose concerns are dismissed by their seniors. We cannot hope to achieve transparency or the opportunities to learn from poor practice if fear is allowed to remain. It needs to be replaced with a culture of honesty and humility - for a bereaved family to know that a mistake has been addressed and won't be repeated makes a significant difference to coming to terms with their loss.

February 22, 2010

General Elections are rightly fought on the government's record of achievement. There are many things that in theory should be above politics - I won't start a list as it will distract from the main point - which is that elderly social care must be one of the failures on which Labour should be held to account.

Labour came to power in 1997 with Frank Dobson, the then SoS for Health saying that the situation couldn't carry it on as it was. Lord Sutherland was tasked with heading a commission to come up with an new plan. He did in 1999, but he was being briefed against even before it was published and it was duly shelved in England (whereas the Scots implemented the recommendation to provide free care at home) and no alternatives were pursued. The subject has of course been reviewed regularly, notably by Wanless, who was also ignored. No remodelling has meant elderly people had their care withdrawn because they no longer satisfied 'critical' or 'substantial' criteria and others have had to sell their homes.

As has often been said, how a nation treats their elderly is measure of its civilisation. Any elderly person will tell you that growing old is a massive adjustment, all the more so now as our expectations of comfort and relief, and our knowledge of what care is possible are that much higher. However the anxieties that many elderly people are experiencing are unacceptable. I have had elderly patients weeping uncontrollable tears as they have told of care services being withdrawn - not being able to have a bath or to sit down with a cup of tea (because you are too wobbly to carry it) doesn't sound like much until you imagine never being able to do these things again.

The Tories have a suggested an optional insurance of £8k, which I imagine it should be possible to add to a mortgage, and would ensure homes don't have to be sold to pay for care. But for non-home owners the funding will still have to be found and I believe it is right that we make this a funding priority. The Lib Dems plans are still vague and giving carers time off is already enabled by many existing charities. As I argue in the 2020health manifesto coming out next week, there are many ways we should be tackling the unreasonable demands made on the NHS which would translate into savings. Whether by appealing to people's altruism today or their self-interest for tomorrow, the case for improved funding for elderly care must be made.

January 28, 2010

It's just been announced by the GMC that Dr Andrew Wakefield has been found guilty of unethical research practices. Along with some journalist's bellows and the deafening silence of Leo Blair's jab record, he fanned the flames of uncertainty about the safety of the MMR vaccine.

The GMC could not have found any other way: Dr Wakefield was in the pay of lawyers acting on behalf of families who were preparing a case against MMR, eventually receiving over £435,000 in fees. He undertook invasive testing on children that he said were in the interests of the children's own clinical care, not for research. And he did not publish his researcher's findings because they showed no evidence of any link between MMR and autism. Let me be clear - there never was any evidence of a link.

Although he did not jeopardise the health of our country's children all by himself, he should now be struck off the GMC register. MMR vaccination rates plummeted, they are still very low in some areas of London, and as a result of the lack of scrutiny of his original publications by those reporting them which would have revealed the paucity of the data, thousands of children have contracted measles over the past few years because they didn't receive their immunisation.

I still know parents who haven't had their children immunised. The success of public health measures like vaccination mean that people don't see the results of the illnesses they are protecting their children from. Measles can cause neurological and respiratory complications; mumps can cause sterility, deafness, meningitis and pancreatitis; congenital rubella syndrome can cause profound disabilities in the unborn.

What we need now is the same number of journalists and celebrities who jumped on the autism-MMR band-wagon to publicise that they have protected their children from these diseases, and perhaps we can put a stop to this contemporary, disastrous myth. And yes, both my children have had all their jabs.

December 14, 2009

Choose and Book (C&B) is one of the successes of NHS IT, with the programme provided by Cerner's e-booking software. The software is working well, but things are getting in the way of smooth success.

The
first obstacle was me. I had lost my paperwork. A call to C&B told
me I could get my password from my GP practice. I called; it would take
15 minutes to retrieve it, they'd call me back. They didn't, so I
called again later. Password lost, could I call back. Third time lucky,
I had my password. Back to C&B to book my hospital appointment. Ah,
now for that hospital they don't use C&B, you have to call direct. I called direct. Ah, now for that
speciality we aren't making bookings because we are full and your
appointment would exceed the waiting limit allowed, I was told. "But we
can put you on the waiting list to be called to make an appointment".
When will you call me? Oh - sometime in the New Year.

Moral of
the story: software is working fine, but people are getting in the way,
and don't believe what you read about the 18 week target success.

December 07, 2009

A coordinated announcement is expected today that brings together the Departments of Health, Work and Pensions, Justice, Home and Local Government on the subject of tackling mental health. As I write the details aren't yet clear but the emphasis will be on offering 'cognitive behaviour therapy' (CBT) to help try and treat and prevent mental illness, for those in school to those out of work. Our understanding is that there will be no new money, but funding will be diverted from Departments which expect to see savings as a result of upstream investment in treatment.

The impact will be in the detail. As 2020health are currently running a project on 'work as a health outcome' we are particularly interested in this announcement. What we want to see is a much greater awareness of how important work is for health, as well as health for work. Enabling people to have control over their 'working lives' through rapid support given to them in times of ill health is a worthy investment for the economy, quite apart from being the right thing to do. So far reports of CBT support for the 'medium term' unemployed don't sound promising - it needs to be offered as soon as someone becomes unfit for work.

But in principle this strategy is to be welcomed. In March 2009, Theresa May made a speech along similar lines, describing the DEL (departmental expenditure limits) - AME (annually managed expenditure) 'switch' whereby the resources to get people back to work can be found from savings in the welfare budget. Where health professionals fit in to the plans to be launched today, but the currently the challenge remains: how to reconnect the outcome of being able to work with healthcare practice.

November 02, 2009

My son has been in tears and I’ve got my perspective back. Both
were achieved last week by taking my family to join two others to play on the
other side of the EU in a Bulgarian orphanage. The EU, but not as we know it.
No rule of law, so precious little infrastructure capable of receiving EU
funding (let alone implementing directives!) and social security here lasts
for 3 months, after which the options are family and friend’s support, begging
or crime. The children we visited aren’t strictly orphans; these are children
abandoned by their parents due to poverty, neglect or both and handed over to State
institutional care.

Like other eastern bloc countries Bulgaria has been an independent
republic for nearly 20 years since the fall of communism. But with the average
monthly salary still only €200, these years have seen a huge brain drain with
800,000 choosing to emigrate rather than struggle on against corruption and
pitiful pay.

The orphanage we visited was two hours outside of Sophia and
situated on a beautiful hillside, this week framed by stunning autumn foliage.
Inside, forty-three 3-7 year olds eat, sleep and play. None of them were
disabled though several showed signs of mental retardation and a significant
number had eye defects. After the first day I walked away happy to have been
there, but by the end of day two I was in meltdown. My teenage daughter asked
me to save my big cry and resulting red eyes until after dinner. It wasn’t the
cockroaches that appeared out of the breadbasket at lunch time in our restaurant.
It wasn’t the bare surroundings. It wasn’t the cries of ‘Mama’ that they insisted
on calling me. It wasn’t noticing that all clothes were shared not owned. It
wasn’t having to peel apart the fingers from behind my neck as it came to
unlocking their embrace when our sessions were over. It was the knowledge of
their future.

Their future is currently utterly bleak. Most are abandoned
but not disowned, so they can’t be adopted. The spectre of a returning parent
can be a threat to their stability, because whether they are reclaimed or
whether they go on to the next orphanage when they are 7, the same fate of begging,
crime or prostitution is the usual outcome – and at a younger age if the family
request their return. Rejected at birth they are usually rejected at school by
their peers and few make it into work.

September 07, 2009

My premise is this: the Daily Mail has got its health headline priorities the wrong was around today (ok - no big shock - but it's significant). It's put the long-term-maybe ahead of the immediate-for-certain. Genes trump Geriatrics. But whilst I am passionate about greater engagement of the public with science and want more mainstream coverage of research, I am also horrified about the way we are treating our elderly.

The main splash is about a 'Giant leap in Alzheimers fight that COULD spare 100,000 sufferers every year'. Three new genes have been identified with Alzheimers, which is great, but without going into detail, this still means practically that there are (probably) many more genes to find and even when we do, genetic based testing, prevention and /or treating are still decades away. I am a sincere advocate of much more research into dementia, it's been grossly underfunded considering the rising prevalence.

But the subheading is about the certainty that home care that WILL be withdrawn from the elderly this winter. By next year the percentage of elderly classified as having 'moderate' homecare needs and getting free help from social services will have dropped from 31% to 14%. I have sat in the lounge of elderly people who have wept openly before me as they show me letters of having care withdrawn. Practically for them this could mean less fresh food or no bath or sitting in the same chair all day (and being forced to wear incontinence pads). They seem to always be the easy target for cuts, behind closed doors and loathe to complain.

What is a possible breakthrough of science has trumped in our headlines a certain, tragic breakdown of society. It reflects a shocking lack of compassion for those who have gone before us. The solutions are multiple - everything from encouraging through our culture a higher regard for the elderly to ensuring social service resources are prioritised on the most vulnerable (children and elderly) first. Think of the irony - we find a cure for dementia but have meanwhile abandoned the elderly to isolation and neglect.

August 19, 2009

The smear-a-peer reached new depths today with the Times allegations of embarrassment against the Tory shadow health minister Lord McColl. Iain Dale has already blogged as someone who doesn't know him, but having known Ian McColl for 17 years I wanted to add some more perspective.

In brief, this is a man whose Christian faith has driven a career which has been dedicated to not just to 50 odd years of NHS surgery but to human rights and social justice. He spends up to 3 months a year unpaid on board a Mercy Ship undertaking life-saving and sight-saving operations off the coast of Africa, often accompanied by his GP wife; a man who promoted compassion for Aids victims through his involvement in setting up Europe's first palliative care centre in 1988, the Mildmay Hospice; who then continued this work in Uganda; who was awarded his life peerage for services to the disabled and to medicine; who has supported the work of the Leprosy Mission (he may still be its president). I could go on with stories of his incredible generosity and philanthropy, but he would be mortified if I did.

The only embarrassment that should be felt today is that of the Times journalists who cannot have failed to discover some of the above compassionate activity as they scraped around in no-news-season, like urban foxes in your dustbins, to deliver a summer shocker: that Lord McColl believes in freedom of choice in healthcare.

July 23, 2009

While we debate how to sustain our universal, free healthcare (see ConHome yesterday), Obama is burdened with how to obtain universal healthcare. As the Times says today, it defeated Clinton and the people and professionals are not liking what they are being offered this time either. An article in the New York Post today sets out the reasons why.

July 06, 2009

NHS IT - what can I say? Well in the light of today's Times headlines "Google or Microsoft could hold NHS patient records say Tories" quite a lot. The Times totally conflate minor and major objectives and call the entire NHS IT 'Connecting for Health' programme 'the electronic patients records programme' and imply the latter will cost £12.4Bn.

The reality is that the use of Microsoft, Google or any other electronic record system would only apply to the summary care record of the 'NHS spine' which has a contract value of £600m. The NHS spine has many other elements which are valuable and would need retaining under any model. For instance the personal demographics service, all the national security and confidentiality provisions as well as the means to support valuable national applications such as 'Choose and Book' and Electronic Transfer of Prescriptions. Both the latter are up and running but need developing further - the former particularly with respect to long term conditions.

Granted there were two major problems with this project right from the start. Firstly the Government took a command and control approach that prevented hospitals finding their own providers and IT solutions. Result - chaos and wasted millions. Secondly calling the whole project an 'IT' programme. Not only was the name the kiss of death but the goal wasn't 'IT' in itself, and the approach alienated clinicians right from the start instead of involving them. The project is about (amazingly) improving patient care [remember that?] through enabling technology. The 2020health-EDS/Hewlett Packard conference on Improving patient outcomes with IT in May (written up here in e-health insider) had superb examples of how technology has transformed patient care in the USA, Spain and Norway (publication to follow).

The major challenge for the Conservatives is how they will support the complex major areas of the project - the local Care Records Service which are the new hospital systems to support clinical functionality needed within hospitals for patient care. Google and Microsoft have no relevance here.

Prescription charges for some people [low paid, diabetics, pensioners] should not be brought back in order to raise money. They should be brought back for everyone to help reverse our dependency culture and reinforce the message that we need to be in more control of our own healthcare, including being responsible when obtaining medication.

We argued for a nominal charge of £1 in 2020health's report last year: 'Our health, our money, our say' (sorry image slightly blurry, it's not your eyes!) To summarise the argument for this:

Unused medication in our bathroom cabinets cost the taxpayer (a conservative estimate) about £800m a year - 10% of the annual medicine budget.

Even for the average pensioner on 38 prescriptions a year, the weekly cost would work out at an affordable 70p per week. Judging from the mountains of repeat medications piled up in the homes of patients I have visited, it wouldn't even come to that.

A small charge would encourage forethought about for example genuine need, stockpiling of medication, whether the GP should be consulted for a minor ailment that could be dealt with by a pharmacist or self-care etc.

The current situation in England is unfair - if you have Aids you have to pay for your meds; if you have diabetes you don't. Where's the logic?

If we are starting afresh and being honest about healthcare, this is a move to level the playing field. We've had means tested prescription charges since 1951. A responsible way forward is to encourage each of us to think about what meds we need and the most appropriate place to get them. A free-for-all system would result in just that, and the wastage bill would soar.